■ High rates of exhaustion and depersonalization are driving many to consider leaving practice, which would exacerbate doctor shortages and affect patient care, experts say.

The many rigors and stresses of medical practice mean that physicians experience burnout at higher rates than the general population. They work an average of 10 hours more per week and are nearly twice as likely to be dissatisfied with their work-life balance, according to an Archives of Internal Medicine study published online Aug. 20.

The pressures place further stress on an already strained health care system, with more doctors choosing to retire early or shift away from clinical practice, said lead study author Tait D. Shanafelt, MD, a professor of medicine in the Dept. of Internal Medicine at Mayo Clinic in Rochester, Minn.

“The very high prevalence of burnout among U.S. physicians is concerning and, based on previous studies, has potential serious implications for quality of care,” he said.

Researchers surveyed 7,288 physicians nationwide and found that 45.8% reported experiencing at least one symptom of serious burnout, such as emotional exhaustion, depersonalization and a low sense of personal accomplishment. Of the surveyed physicians, the study compared 6,179 practicing doctors ages 29 to 65 with 3,442 workers of the same age group in other fields. Doctors had a higher risk of emotional exhaustion (32.1% versus 23.5%) and overall burnout (37.9% versus 27.8%).

The findings indicate a broader problem with the overall health care system, said study co-author Sonja Boone, MD, director of physician health and health care disparities at the American Medical Association.

“It’s a systemic problem. It’s not just that some physicians have high-risk personalities,” she said.

Those challenges are compounded by rising demands for care from aging baby boomers and a projected 30 million newly insured patients under the Affordable Care Act, said Doris C. Gundersen, MD, medical director of the Colorado Physician Health Program and president-elect of the Federation of State Physician Health Programs.

“More and more physicians are presenting with mental health concerns, including burnout,” Dr. Gundersen said. “Nationally, the statistics bear out that physicians have a suicide rate two to four times greater than the general population. Some physicians have contended with increasing stress by working fewer hours or retiring early. This does not bode well for the needs of our nation.”

Increasing burdens of care

The study’s findings were not surprising, said Clifford Lyons, MD, medical director of The Foundation of the Pennsylvania Medical Society’s Physicians’ Health Program. The program has received an increasing number of calls from hospitals and physicians struggling with burnout-related issues, such as drug and alcohol addiction.

The doctor-patient relationship is still the most meaningful aspect in medicine, but doctors can lose sight of that, Dr. Lyons said. Many doctors feel overwhelmed. They often are called on to make life-or-death decisions and are inundated constantly with new information, new studies and new regulatory requirements. On top of that, they may worry about being sued by a patient or cited by a medical licensing board.

“A lot of times we’re held to a standard of perfection, and if you make a mistake, there is a punitive consequence to that,” he said.

Physicians have faced increasing administrative burdens over the last 20 years, such as insurance companies requiring prior authorization for certain procedures and prescriptions, Dr. Gundersen said.

“Denial of payment for services rendered was a more rare situation [before the 1990s] compared to today,” she said. “Insurance entities did not intrude as deeply into a physician’s practice. In today’s climate, physicians must not only deliver competent clinical care but also spend time justifying their medical recommendations to third-party payers.”

Front-line physicians often affected

The study found significant differences in burnout by specialty. Some of the highest rates were among physicians serving on the “front lines” in family medicine, general internal medicine and emergency medicine, Dr. Shanafelt said.

Emergency physicians work long hours and spend a lot of holidays, nights and weekends away from their families, said Ryan A. Stanton, MD, president-elect of the Kentucky chapter of the American College of Emergency Physicians. As the safety net for people without regular primary care, emergency physicians are seeing more and more patients. They must balance those demands with limited resources and increasing pressures to cut costs, he said.

“The expectations and the stress upon us is going up and up and up,” said Dr. Stanton, medical director of the emergency department at the University of Kentucky Good Samaritan Hospital. “ER physicians average about three patients per hour, so it doesn’t leave a lot of time.”

A major challenge for primary care physicians is that the current payment system doesn’t reward preventive care, such as phone counseling to help patients manage chronic disease, said David Bronson, MD, a general internist and president of the American College of Physicians. The burdens are worsening as physicians must contend with the costs and hassles of implementing new quality reporting standards and electronic health records, he said.

“This is one of the reasons many physicians are becoming employed. They can’t sustain their practices,” Dr. Bronson said.

Loss of autonomy is another challenge, especially as more doctors become employed and cope with having their decisions constantly questioned, said Glen Stream, MD, president of the American Academy of Family Physicians. Sixty percent of the AAFP’s members are in employed positions.

“One of the things that frustrates physicians is a sense of powerlessness,” Dr. Stream said. “People are working hard, they’re working long hours and they’re working faster. They’re not able to provide the kind of attentive care that they would like.”

The higher rates of burnout among primary care physicians are particularly concerning, given that they are key to many of the elements of health system reform, Dr. Shanafelt said.

“This snapshot of physician burnout prior to the Affordable Care Act taking effect suggests many primary care physicians are already functioning at their limit,” he said.

Taking steps to reduce burnout

High burnout rates are driving many physicians to move away from clinical practice and could deter some from entering the profession, Dr. Bronson said. It also means that fewer medical students are choosing primary care.

“The system just chews you up,” Dr. Lyons said. “It’s sad to see other doctors who are so stressed that they’ve walked away from medicine.”

Dr. Stanton said many of his colleagues are considering changing careers or retiring early.

“Everybody I work with is looking down the road to when they will get out of medicine,” he said. “It’s going to leave us without anyone to see these patients.”

Burnout among doctors has reached a critical level, and the study authors hope their findings will help motivate systemic changes, said Dr. Boone, of the AMA. “It needs to sound an alarm that this is a crisis situation,” she said.

The AMA’s Healthier Life Steps: A Physician’s Guide to Personal Health and its companion piece, Practical Steps to Resilience, are geared at helping physicians recognize and cope with burnout, anxiety, depression and suicidal thoughts, she said.

Dr. Shanafelt said there’s a pressing need for research to identify what organizational changes can best help to reduce burnout. “We hope these findings will encourage large practice groups, hospitals, academic medical centers, government payers and other health care organizations to begin to explore what system changes can be made to help address this problem,” he said.

Any solution needs to be a combination of assisting individual physicians and working to solve the root causes of burnout in the profession, Dr. Lyons said. Often, physicians who struggle with burnout self-medicate. They may take sleeping pills to cure insomnia or narcotics for headaches. Because of the high expectations of the profession, some doctors may wait years to seek help.

“We tend to be isolated,” Dr. Lyons said. “We’re taught to be in control and not to show weakness, so it’s hard to ask for help.”

The Pennsylvania Physicians’ Health Program works one-on-one to guide physicians in getting the help they need — such as additional clinical training and treatment for mental illness and substance abuse.

Finding solutions to broader systemic issues is difficult, Dr. Stanton said. Most people agree that the health system needs to be changed, but reaching consensus on what those changes should be is challenging.

Some changes already under way will have a positive impact, such as the expansion of the medical home model of care that emphasizes team-based care, he said. There also needs to be more emphasis on primary and preventive care and greater efforts to reduce physician shortages.

The medical profession needs to do more to reinforce work-life balance concepts early in the training of medical students and residents, and educate practicing physicians about stress management, Dr. Gundersen said.

“A gradual change in the culture of medicine, which has traditionally reinforced workaholism, needs to occur so that vacations, exercise, spiritual practices and emphasis on supportive relationships become the norm,” she said.